Provider Demographics
NPI:1316260839
Name:CARLISLE, MARLA D (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:D
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARLA
Other - Middle Name:D
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:605 THIRD AVENUE, SUITE B
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420
Mailing Address - Country:US
Mailing Address - Phone:567-201-2890
Mailing Address - Fax:
Practice Address - Street 1:605 THIRD AVENUE, SUITE B
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420
Practice Address - Country:US
Practice Address - Phone:567-201-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006448363AM0700X
OH50.003055363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0071368Medicaid
OH0071368Medicaid
OHP01618687Medicare PIN
OHH422920Medicare PIN